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To the Editor:-We report a case where vigilance by our Anesthesia Pain Management Clinic aided in prompt diagnosis and treatment of a patient with unrecognized spinal meningitis. A 39-yr-old healthy man underwent uneventful outpatient extracorporeal shockwave lithotripsy with combined spinal epidural anesthesia (27-gauge Whitacre spinal needle through 18-gauge Tuohy needle, Becton Dickinson, Franklin Lakes, NJ). Two days after surgery, the patient experienced a bilateral, occipital-temporal headache that worsened with an upright position. The patient was evaluated by his primary care physician and referred to the pain management clinic for an epidural blood patch with a presumptive diagnosis of postdural puncture headache. Further evaluation at the pain management clinic revealed acute development of photophobia and severe headache (6/10 on a verbal pain scale) while supine that worsened when upright (9/10). Vital signs were remarkable for a tympanic membrane temperature of 38.5 degrees Celsius. Physical examination was remarkable for an ill-appearing man with a positive Kernigs sign of meningeal irritation. The patient's spinal needle puncture site was nonerythematous and nontender. A blood cell count was acquired, which revealed a leukocytosis (14,000/mm3) with 83% polymorphonucleocytes. Based on these physical and laboratory findings, we decided to proceed with a diagnostic lumbar puncture rather than an epidural blood patch. Lumbar puncture revealed turbid cerebrospinal fluid with numerous gram-positive diplococci. Additional cerebrospinal studies revealed 9,000/mm3white blood cells (normal at our institution, 0-5/mm3), 184 mg/dL protein (normal, 18-58), and 11 mg/dl glucose (normal, 40-70). The patient was transferred to the internal medicine service, treated with vancomycin and ceftazadine, and discharged in good condition after 5 days in the hospital. Although no organisms were cultured from the cerebrospinal fluid, the Infectious Disease service believed that the patient's findings were consistent with bacterial meningitis caused by Streptococcus pneumoniae.

Postdural puncture headache is an uncommon (incidence 1-3%) but expected complication after spinal anesthesia with small, noncutting needles. [1] Spinal meningitis is an extremely rare finding after spinal anesthesia. [2] In this case, a causal relation between the patient's meningitis and spinal anesthesia is unclear, because S. pneumoniae is the most common community-acquired pathogen for spinal meningitis in adults. [3] Pneumococcal meningitis is a life-threatening medical emergency (approximately 25% mortality), and delay in instituting appropriate therapy worsens outcome. [3] Prompt diagnosis and institution of antimicrobial therapy aided in this patient's full recovery. As anesthesiologists expand into perioperative medicine, we encourage continued vigilance as consultants outside the operating suites.